SPINAL INJURY Definition Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary

or permanent, in its normal motor, sensory, or autonomic function Background Patients with spinal cord injury (SCI) usually have permanent and often devastating neurologic deficits and disability. The goals for the emergency physician are to 1. Establish the diagnosis 2. Initiate treatment to prevent further neurologic injury from either pathologic motion of the injured vertebrae or secondary injury from the deleterious effects of cardiovascular instability or respiratory insufficiency Pathophysiology Anatomy  The spinal cord is divided into 31 segments, each with a pair of anterior (motor) and dorsal (sensory) spinal nerve roots. On each side, the anterior and dorsal nerve roots combine to form the spinal nerve as it exits from the vertebral column through the neuroforamina.  Spinal cord ends at lower margin of the L1 vertebral body.  Thereafter, the spinal canal contains the lumbar, sacral, and coccygeal spinal nerves that comprise the cauda equina.  Therefore, injuries below L1 are not considered SCIs because they involve the segmental spinal nerves and/or cauda equine.  The spinal cord organized into a series of tracts or neuropathways that carry motor (descending) and sensory (ascending) pathways.  The corticospinal tracts are descending motor pathways located anteriorly within the spinal cord. Axons extend from the cerebral cortex in the brain as far as the corresponding segment, where they form synapses with motor neurons in the anterior (ventral) horn. They decussate (cross over) in the medulla prior to entering the spinal cord.  The dorsal columns are ascending sensory tracts that transmit light touch, proprioception, and vibration information to the sensory cortex. They do not decussate until they reach the medulla.  The lateral spinothalamic tracts transmit pain and temperature sensation. These tracts usually decussate within 3 segments of their origin as they ascend.  The anterior spinothalamic tract transmits light touch.  Autonomic function traverses within the anterior interomedial tract.

Neurogenic shock refers to the hemodynamic triad of hypotension, bradycardia, and peripheral vasodilation resulting from autonomic dysfunction and the interruption of sympathetic nervous system control in acute SCI. It does not usually occur with SCI below the level of T6. Blood supply  The blood supply of the spinal cord consists of 1 anterior and 2 posterior spinal arteries.  The anterior spinal artery supplies the anterior two thirds of the cord. injury to this vessel results in dysfunction of the corticospinal, lateral spinothalamic, and autonomic interomedial pathways.  Anterior spinal artery syndrome involves paraplegia, loss of pain and temperature sensation, and autonomic dysfunction.  The posterior spinal arteries primarily supply the dorsal columns.  The anterior and posterior spinal arteries arise from the vertebral arteries in the neck and descend from the base of the skull. Various radicular arteries branch off the thoracic and abdominal aorta to provide collateral flow  At any given level of the spinal cord, the central part is a watershed area. Cervical hyperextension injuries may cause ischemic injury to the central part of the cord, causing a central cord syndrome. Etiology SCIs may be primary or secondary. Primary SCIs


 

Arise due to direct effect of the trauma on the spine. This follows compression or severe angulation of the vertebral spine. This leads to mechanical disruption, transection, or distraction of neural elements. This injury usually occurs with fracture and/or dislocation of the spine. However, primary SCI may occur in the absence of spinal fracture or dislocation just by severe distraction thus the term SCIWORA (spinal cord injury without radiologic abnormality)

 Penetrating injuries due to bullets or weapons may also cause primary SCI. More commonly, displaced bony fragments cause penetrating spinal cord and/or segmental spinal nerve injuries.  Extradural pathology may also cause a primary SCI. Spinal epidural hematomas or abscesses cause acute cord compression and injury.
 Spinal cord compression from metastatic disease is a common oncologic emergency.

Sympathetic nervous system fibers exit the spinal cord between C7 and L1, while parasympathetic system pathways exit between S2 and S4.

Injury manifestation  Injury to the corticospinal tract or dorsal columns, respectively, results in ipsilateral paralysis or loss of sensation of light touch, proprioception, and vibration.  injury to the lateral spinothalamic tract causes contralateral loss of pain and temperature sensation  Anterior cord injury causes paralysis and incomplete loss of light touch sensation (lateral spinothalamic spared.)

Secondary SCI’s -Vascular injury to the spinal cord caused by arterial disruption, arterial thrombosis, or hypoperfusion due to shock are the major causes of secondary SCI. -Anoxic or hypoxic effects compound the extent of SCI. -Movement around unstable spinal column causing further injury Spinal cord injuries syndromes 1. Complete cord injury complete loss of motor and sensory function below the level of the traumatic lesion. 2. Incomplete cord injury partial loss of sensory and/or motor function below the level of injury. The incomplete SCI syndromes are further characterized clinically as follows: a) Anterior cord syndrome involves variable loss of motor function and pain and/or temperature sensation, with preservation of proprioception.

 

Spinal shock is defined as the complete loss of all neurologic function, including reflexes and rectal tone, below a specific level that is associated with autonomic dysfunction. Autonomic function is transmitted in the anterior interomedial tract. Progressively higher spinal cord lesions or injury causes increasing degrees of autonomic dysfunction(lower exit of roots

JUDY WAWIRA GICHOYA yr 2007

1

B) Brown-Séquard syndrome(hemi-section cord) ipsilateral loss of proprioception and motor function, with contralateral loss of pain and temperature sensation. c) Central cord syndrome usually involves a cervical lesion, with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Sensory loss is variable, and the patient is more likely to lose pain and/or temperature sensation than proprioception and/or vibration. Dysesthesias, especially those in the upper extremities (eg, sensation of burning in the hands or arms), are common. Sacral sensory sparing usually exists. d) Conus medullaris syndrome is a sacral cord injury with or without involvement of the lumbar nerve roots. This syndrome is characterized by areflexia in the bladder, bowel, and to a lesser degree, lower limbs. Motor and sensory loss in the lower limbs is variable. e) Cauda equina syndrome involves injury to the lumbosacral nerve roots and is characterized by an areflexic bowel and/or bladder, with variable motor and sensory loss in the lower limbs. Because this syndrome is a nerve root injury rather than a true SCI, the affected limbs are areflexic. This injury is usually caused by a central lumbar disk herniation. A spinal cord concussion is characterized by a transient neurologic deficit localized to the spinal cord that fully recovers without any apparent structural damage. Spinal shock -Spinal shock is a state of transient physiological (rather than anatomical) reflex depression of cord function below the level of injury with associated loss of all sensorimotor functions. Present with: 1.Hypotesion 2.Hypothermia 3.Bradycardia 4.Flaccid paralysis 5.Loss of sensation 6.Areflexia or depressed reflexes 7.Urinary and bladder incontinence. 8.Sweating . 9.Sometimes sustained priapism develops. These symptoms tend to last 24-48hrs. Until the return of the bulbocarvenosus reflex and the anal wink. The diagnosis of complete spinal cord injury cannot be made until the period of spinal shock is over, as evidenced by the return of the bulbocavernosus reflex. To elicit this reflex, the clinician digitally examines the patient's rectum, feeling for contraction of the anal sphincter while squeezing the glans penis or clitoris. Neurogenic shock Neurogenic shock is manifested by the triad of hypotension, bradycardia, and hypothermia. Shock tends to occur more commonly in injuries above T6, secondary to the disruption of the sympathetic outflow from T1L2 and to unopposed vagal tone, leading to decrease in vascular resistance with associated vascular dilatation. Neurogenic shock needs to be differentiated from spinal and hypovolemic shock. Hypovolemic shock tends to be associated with tachycardia DIAGNOSIS History -Ascertaining the mechanism of injury is also important in identifying the potential for spinal injury.Fall with neck hyperextension/flexion, back trauma etc. -Symptoms related to the vertebral column (most commonly pain) and any motor or sensory deficits.

-Hemorrhagic shock may be difficult to diagnose because the clinical findings may be affected by autonomic dysfunction.. -To distinguish hemorrhagic shock from neurogenic shock: Neurogenic shock occurs only in the presence of acute SCI above T6. Hypotension and/or shock with acute SCI at or below T6 are caused by hemorrhage. Physical exam: -As with all trauma patients, initial clinical evaluation begins with a primary survey.-ABCDE.An SCI must be considered concurrently. Spinal exam should involve: a)Pulmonary function – respiratory rate, cyanosis, respiratory distress, air entry bilaterally, added sounds, chest wall expansion, abdominal wall movement, cough, and chest wall and/or pulmonary injuries. Arterial blood gas (ABG) analysis and pulse oximetry Respiratory dysfunction is ultimately dependent on preexisting pulmonary comorbidity, the level of SCI, and any associated chest wall or lung injury. Any or all of the following determinants of pulmonary function may be impaired in the setting of SCI: 1.Loss of ventilatory muscle function from denervation and/or associated chest wall injury 2.Lung injury, such as pneumothorax, hemothorax, or pulmonary contusion 3.Decreased central ventilatory drive that is associated with head injury or exogenous effects of alcohol and drugs. b)CVS-Pulse rate and volume, BP (hemorrhagic or neurogenic shock c)Temperature-Hypothermia-spinal shock d)Thorough Neurological Examination Spinal level or decide whether complete or incomplete injury Motor exam-Bulk, Tone, Power, Reflexes, Co-ordination In all patients, assessment of deep tendon reflexes and perineal evaluation is critical. The presence or absence of sacral sparing is a key prognostic indicator. The sacral roots may be evaluated by documenting the following: -Perineal sensation to light touch and pinprick -Bulbocavernous reflex (S3 or S4) -Anal wink (S5) -Rectal tone -Urine retention or incontinence -Priapism Sex: The male-to-female ratio is approximately 2.5-3.0:1. Age: About 80% of males with SCIs are aged 18-25 years. SCIWORA occurs primarily in children. Motor testing for spinal level: • C5 - Elbow flexors (biceps, brachialis) and shoulder abduction • C6 - Wrist extensors (extensor carpi radialis longus and brevis) • C7 - Elbow extensors (triceps) • C8 - Finger flexors (flexor digitorum profundus) to the middle finger • T1 - Small finger abductors (abductor digiti minimi) • L2 - Hip flexors (iliopsoas) • L3 - Knee extensors (quadriceps) • L4 - Ankle dorsiflexors (tibialis anterior) • L5 - Long toe extensors (extensors hallucis longus) • S1 - Ankle plantar flexors (gastrocnemius, soleus) SENSORY testing for spinal level • C2 - Occipital protuberance • C3 - Supraclavicular fossa • C4 - Top of the acromioclavicular joint

JUDY WAWIRA GICHOYA yr 2007

2

• • • • • • • • • • • • • • • • • • • • • • • • •

C5 - Lateral side of arm C6 - Thumb and lateral aspect forearm C7 - Middle finger C8 - Little finger T1 - Medial side of arm T2 - Apex of axilla OR 2nd intercostals space T3 - Third intercostal space (IS) T4 - 4th IS at nipple line T5 - 5th IS (midway between T4 and T6) T6 - 6th IS at the level of the xiphisternum T7 - 7th IS (midway between T6 and T8) T8 - 8th IS (midway between T6 and T10) T9 - 9th IS (midway between T8 and T10) T10 - 10th IS or umbilicus T11 - 11th IS (midway between T10 and T12) T12 - Midpoint of inguinal ligament. L1 - Half the distance between T12 and L2 L2 - Mid-anterior thigh L3 - Medial femoral condyle or lateral femoral condyle L4 - Medial malleolus or medial aspect leg L5-lateral aspect of leg or lateral malleolus or Dorsum of the foot at third metatarsophalangeal joint S1 - Lateral heel S2 - Popliteal fossa in the midline S3 - Ischial tuberosity S4-5 -Perianal area (taken as one level.

MRI is best for suspected spinal cord lesions, ligamentous injuries, or other nonosseous conditions. MRI may be used to evaluate nonosseous lesions, such as extradural spinal hematoma; abscess or tumor; and spinal cord hemorrhage, contusion, and/or edema. Motor strengths and sensory testing The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification), using the following categories: A - Complete: No sensory or motor function is preserved in sacral segments S4-S5. B - Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5. C - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3. D - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3. E - Normal: Sensory and motor functions are normal. MANAGEMENT Starts at the site of injury follow: Principles of management 1. The injury must be recognized. 2. Measures to prevent further damage ("secondary" injury) and to detect deteriorating neurologic function so that corrective measures can be taken. 3. The patient must be maintained in optimal condition to allow the greatest possible nervous system repair and recovery. 4. Evaluation and rehabilitation of the patient must be actively pursued to maximize the function of surviving but dysfunctional nervous tissue Pre-hospital -ABC of resuscitation -stabilize and immobilize the spine thus cervical column and transport patient on hard board. Transportation can by ambulances in short distances but if possible air lift is better to avoid movements that would interfere with splinting. Casualty -Keep the cervical collar and patient on the backboard -Resuscitation following ABCDE should be done. Airway Securing the airway while keeping the cervical column in place may be challenging -The cervical spine must be maintained in neutral alignment at all times. Clearing of oral secretions and/or debris is essential to maintain airway patency and to prevent aspiration. The modified jaw thrust and insertion of an oral airway may be all that is required to maintain an airway in some cases. However, intubation may be required in others. Breathing Management for pulmonary complications and/or injury in patients with SCI includes supplementary oxygen for all patients and chest tube thoracostomy for those with pneumothorax and/or hemothorax Circulation -Hypotension may be hemorrhagic and/or neurogenic in acute SCI. This should be urgently corrected to prevent secondary SCI

Sensory testing –pain,tempetature,crude and fine touch and proprioception. Neurologic level of injury - Most caudal level at which both motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2 Sensory level - Most caudal dermatome with a normal score of 2/2 for both pinprick and light touch Motor level - Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5) INVESTIGATIONS Lab Studies: 1.Hemoglobin and/or hematocrit levels may be measured initially and monitored serially to detect or monitor sources of blood loss. 2.Perform urinalysis to detect associated genitourinary injury Imaging Plain x-Ray -The standard 3 views of the cervical spine are recommended: 1.Anteroposterior 2.Lateral view 3.Odontoid view-open mouth x-ray Other oblique views include depressed shoulder view -Anteroposterior and lateral views of the thoracic and lumbar spine are recommended. -The cervical spine radiographs must include the C7-T1 junction to be considered adequate CT Scan CT scanning is reserved for delineating bony abnormalities or fracture. MRI

JUDY WAWIRA GICHOYA yr 2007

3

Judicious fluid replacement with isotonic crystalloid solution to a maximum of 2 liters is the initial treatment of choice. Overzealous crystalloid administration may cause pulmonary edema because these patients are at risk for the acute respiratory distress syndrome. Adequate perfusion with the following parameters should be maintained  Systolic blood pressure (BP) should be 90-100 mm Hg. Systolic.  Heart rate should be 60-100 beats per minute in normal sinus rhythm. Hemodynamically significant bradycardia may be treated with atropine.  Urine output should be more than 30 mL/h. Placement of a Foley catheter to monitor urine output is essential  Prevent hypothermia. NB Associated head injury occurs in about 25% of SCI patients. A careful neurologic assessment for associated head injury is compulsory Inpatient management involves1.Prevention of secondary injury-splints, corticosteroid, oxygen 2.Analgesia 3.Bladder care-Condom catheter 4.Bowel care 5.Skin care 6.Physiotherapy chest and limbs 1)Spilnts Optimal immobilization is obtained by placing the patient supine (face up) on a firm, flat surface (eg, rigid, long spine board) without a pillow and with lateral motion of the neck restricted by a rigid cervical collar (Philadelphia), lateral neck rolls connected with tape across the forehead, or traction. Traction is the most effective method . -Skull traction with a 3-kg (7-lb) weight on a rope off the end of the bed provides the best means of emergency splinting and traction. -Thoracolumbar orthosis TLO only used for injuries below T6,not used above T6 -Halos jacket used for cervical fractures used to hold the cervical spine and thorax -Submental mandible occipital strut)SiMO) -Logrolling the patient to the supine position is safe to facilitate diagnostic evaluation and treatment at least five people needed for leg rolling. 2)Steroids -Treat all SCI patients within 3 hours of injury with the following steroid protocol: methylprednisolone 30 mg/kg bolus over 15 minutes and an infusion of methyl prednisolone at 5.4 mg/kg/h for 23 hours beginning 45 minutes after the bolus. Significant improvement in motor function and sensation in patients with complete or incomplete SCIs noted 3)Analgesics -Use analgesics appropriately and aggressively to maintain the patient's comfort if he or she has been lying on a hard backboard for an extended period. Start of opiod analgesia initially then NSAIDS 4)Bladder care: Condom catheter Monitor input output of fluids initially. Also if loss of bladder function 5)Bowel care -Manual evacuation by sweeping thro the rectum which cause irritation or the use of enemas(warm soap enema) 6-+NG tube -Placement of a nasogastric tube for decompression.

Ileus is common This may also be used for nutritional support. 7-Anti emetics Aspiration pneumonitis is a serious complication in the SCI patient with compromised respiratory function. Antiemetics should be used aggressively 8-Skin care Prevent pressure sores-Denervated skin is particularly prone to pressure necrosis. -Remove belts and back pocket keys or wallets. -Turn the patient every 1-2 hours. -Pad all extensor surfaces. -Use pneumatic mattresses, continuous motion or ripple mattress. -Good nursing care to prevent wetness-ZNO 9-Physiotherapy-both chest and limbs Prevention of contractures and maintenance of range of motion are important in all patients with spinal cord injury and should begin immediately following the injury. Chest physiotherapy to prevent pneumostatic pneumonia SURGICAL TREATMANT The vertebral divided into column (Dennis) 1.Anterior column –include anterior 2/3 of the body, anterior longitudinal ligament, annular ligament and nucleas polposus anterior half. 2.Middle column-posterior 1/3 of the body and PLL plus the nucleus polposus and the annular ligament upto facet joint 3.Posterior column-include lamina, the spinous process and the ligaments plus the ligamnetum flavum. Instability after fractures occur if involvement of at least two columns or most of the anterior column Types of fractures include. 1.Anterior wedge fracture 2.Posterior wedge fracture 3.Burst fracture 4.Subluxation-displaced not out of articulation 5.Dislocation 6.Fracture of spinous process , pedicles, transverse process Decompression Indications for decompression-If a patient has an incomplete spinal cord injury and evidence of continued neural element compression, decompression may be indicated. At the time of surgery, stabilization in the form of fusion, Often accompanied by instrumentation, may be performed. If decompression is felt to be indicated, the surgical approach used should depend on where the compression lies. Similar neurologic outcomes have been reported with anterior decompression and posterolateral decompression. retropulsed bone can be removed or pushed back into place Surgical stabilization In a patient who has a burst fracture in which the posterior elements remain intact, treatment may consist of an anterior vertebrectomy, strut grafting, and fusion without instrumentation. Such a patient can be braced post-operatively without undue risk of graft displacement or spinal instability. Use of rods and pedicle screws Use of cages to stabilize burst fracture SPECIAL CONSIDERATION CERVICAL INJURY Jefferson Injury- 4 fragment fracture of C1.due to shearing and rotation and present with neurological injury Upper cervical fractures the spinal canal is large and accommodates rotation rarely present with neurological deficits. Management by halos jacket.

JUDY WAWIRA GICHOYA yr 2007

4

Hangman injury-hyperextension fractures of C2 pedicle plus fracture of disc between C3 and C4. Classification Type 1-undisplaced fracture of C2. Type 2-displacement less than 3 cm Type 3-displacement greater than 3cm and C2and C3 articulation disrupted Types 1and 2 managed by a Philadelphia collar while type 3 managed by halos jacket which prevents movement in all planes. Philadelphia collar only prevents extension-flexion movement at the neck, rotational and sideway movement can occur. Lower cervical injuries Occur by rotational, compresional and distraction forces Compression occur by axial loading mostly anterior aspect of vertebral body fractured Burst fracture the whole body involved in fracture Facet dislocation can be unifacet or bifacet dislocation Unifacet dislocastion occur when the there is less than 25 % anterolithesis Bifacet dislocation occurs with more than 25 % anterolithesis. Radiology of Cervical Spine X-ray of the cervical spine must see all the cervical vertebrae plus proximal half of T1. 3-views -AP See spinous processes-should be in line. Dislocations and misalignment End plates -Lateral -Odontoid(open mouth view) This done to visualize the odontoid process Classification of Odontoid fractures Type1 avulsion at the tip Heal managed by a collar Type 2 Fracture along the base of odontoid. Worst type. High risk of non union. If less than 5cm displacement then can b managed by halos jacket. Greater than 5cm then internal fixation screw or C1-C2 transarticular screw. Type 3 involves the body-managed by a halos jacket -In interpretation check the soft tissues around the cervical column, the discs spaces the vertebral bodies, retropharyngeal space. The distance anterior to the body of C2 is 6 mm and that anterior to C6 is 2 cm. The 6 at 2 and 2 at 6 rule. The atlantodens distance is usually 3mm and this is increased in the transverse ligament tear. Radiological lines -The anterior and posterior aspect the vertebral bodies curved anteriorly. -Posterior aspect of facets curved anteriorly. -Tips of spinous processes in line -Spinolaminal line curved anteriorly. COMPLICATIONS of spinal injury 1. Neurologic deterioration is the extension of the sensory deficit cephalad. 2. Pressure sores-Careful and frequent turning of the patient is required to prevent pressure sores. 3. Aspiration peumonitis-Nasogastric decompression of the stomach is mandatory. 4. Hypothermia Prevent hypothermia by using external rewarming techniques and/or warm humidified oxygen. 5.Pulmonary complications in SCI are common. Pulmonary complications are directly correlated with mortality, and both are related to the level of neurologic injury. Pulmonary complications of SCI include the following:

-Atelectasis secondary to decreased vital capacity and decreased functional residual capacity -Ventilation-perfusion mismatch due to sympathectomy and/or adrenergic blockade -Increased work of breathing because of decreased compliance -Decreased coughing, which increases the risk of retained secretions, atelectasis, and pneumonia -Muscle fatigue 6.Muscle wasting,joint stiffness and contactures

JUDY WAWIRA GICHOYA yr 2007

5

Sign up to vote on this title
UsefulNot useful